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Is it possible to have a good death?

We spend much of our lives fearing death, so the notion of a 'good death' seems a contradiction in terms. But is it possible to achieve a good death?

[Image source: iStockPhoto | Viktor_Gladkov]

Talk to people about the kind of death people want to avoid and almost everyone has a story to share. It may be of a grandfather diminished and ridiculed by dementia until he is incontinent, incoherent, and bed-bound; or a young friend wracked with the agony of cancer that no amount of morphine can relieve.

If there is such a thing as a bad death, it stands to reason that a good death is also possible. But what makes a good death, and how can it be achieved?

'After 20 years, I have not the vaguest concept of what a good death is,' he says. 'The idea of a good death has connotations beyond being peaceful.'

In 1999, the authors of UK report The Future of Health and Care of Older People came up with a list of principles outlining a good death. They included knowing when death is coming and what to expect, the ability to retain control of what happened, to be afforded dignity and privacy, to have access to hospice care, and to have control over who is present and shares that final experience.

Retired US surgeon and author Dr Bernie Siegel believes that last principle to be especially important.

'When people say, "My brother died," I ask, "What time of day did he die, who was with him when he died?"' Siegel says. "If they say he died at two in the morning alone, I'd say that is not a good death. But if they say he died at two in the afternoon with the family sitting around him, I'd say he was okay... he has not failed anyone and he felt secure in that dying, that you all knew it was the right thing for him."

Principles of a good death

To know when death is coming, and to understand what can be expected

To be able to retain control of what happens

To be afforded dignity and privacy

To have control over pain relief and other symptom control

To have choice and control over where death occurs (at home or elsewhere)

To have access to information and expertise of whatever kind is necessary

To have access to any spiritual or emotional support required

To have access to hospice care in any location, not only in hospital

To have control over who is present and who shares the end

To be able to issue advance directives which ensure wishes are respected

To have time to say goodbye, and control over other aspects of timing

To be able to leave when it is time to go, and not to have life prolonged pointlessly

It's about choice

Another principle critical to a good death, according to the 1999 report, is to have control over pain relief and over other symptom control. This is not so much about having all symptoms taken care of but about having control over how much pain relief and other treatments are given.

This is important because, perhaps surprisingly, not everyone wants to be eased into death. Some, like Dave, choose to face it alert and awake.

After 18 months of suffering from various respiratory problems, Dave was diagnosed with an aggressive secondary tumour growing out of the mastoid bone behind the ear. The tumour was pressing on his brain stem, and it was inoperable.

According to his wife Angela, his attitude was, 'If this is what I have to do, I want to do it. I want to do it well, I want to do it properly, so I just have to get on with it.'

Dave died just eight weeks after the tumour was diagnosed. In his last week, he and his wife struggled at times with the medical staff because Dave was determined to be conscious and aware, which meant compromising his pain relief. The staff also struggled with having someone so obviously suffering physically, but who did not want that relief.

Then one morning, Dave's breathing had changed to a pattern that often heralds death, but he was still conscious.

'He opened his eyes, and I said to him, "Honey, can you see the light?"' Angela recalls.

Dave's answer was a simple nod, but due to the location of his tumour, this nod itself was an extraordinary thing. The tumour was pressing on the nerves that normally enable a nod, so previously the most Dave could manage was the faintest of head tilts. 'But this nod was the chin right forward on the chest and right back,' Angela says. 'It was an absolute definite nod. And I said to him, "Honey, you go into that light and you rest."'

And once again came a clear nod. A few moments later, Dave took his last breath. 'So he was absolutely conscious till the end, which was what he wanted, and how he responded meant he gave me a beautiful gift.'

An easy death

While Dave chose to limit the amount of symptom control he received at the end, most would define a good death as one in which there is little or no suffering.

Medicine has come a long way in managing suffering at the end of life, particularly thanks to the efforts of palliative care, but that doesn't mean death will be pain-free.

In his 20 or so years of experience, Gault has seen the full spectrum of death experiences and believes that the vast majority of patients do achieve what he would consider a 'peaceful' death.

'There will still be ups and downs; we can't remove every single symptom for every minute of every day  that's just not the way the world is,' he says. 'But I've seen it all the way through to the other spectrum, where we've not been able to do much good for any symptoms and it's all been a complete nightmare for everybody concerned.'

Ultimately, death is a lot like birth. Today, women are encouraged to make birth plans to help them achieved a good experience of birth, and death should be no different. If a good death is all about choice and control, then it relies on us as individuals to know what choices we would make, and to take steps to ensure those choices are respected as much as possible.

* some names have been changed

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Comments (13)

Practical cynic :

18 Sep 2013 5:45:43pm

As a nurse who has witnessed death probably a dozen times, though I do believe in lots of the principles mentioned above such respect for advance care directives and access to palliation and pain relief. The "perfect death" like a "natural birth" is not always achievable and even matters that much. Dying people struggle to breathe, get agitated, vomit and gurgle despite the best care and medications. Often I think this is more distressing to the family than the person who I believe is often no longer aware. Also the myth of the epic last words often it is something as mundane as "can I have a drink?" I think the big difference between a "good" death and "bad" death is how accepting the person and family are of mortality.

michael william lockhart :

18 Sep 2013 6:27:26pm

Yes of course we can have a good death, "dying is as natural as being born", there is no reason to fear death, you will be as "aware" as you were before being born, we are entitled to fear pain, fortunately we have anti pain medication these days and they will help,

Mike F. :

Jane :

19 Sep 2013 5:46:02am

What a wonderful, thought provoking article. Thank you! The "Principles of a Good Death" largely ring true. I'm cautious about the second one ("to be able to retain control of what happens"). Experiencing childbirth showed me there is a need for complete surrender to a physical process over which I had very little control. In death, we may be able to choose the environment and who is present to some degree, and to opt for pain relief and spiritual support, but we will have otherwise have little control over the physical process that is going to happen whether we like it or not. So all that will be left to work with is our own mind - it's attachment to life and it's aversion to physical suffering and fear of the unknown. Would regular reflection on this help us get to know our own minds and help us prepare for our own (eventual) death? At least the territory would not be so unfamiliar and we could meet death with less fear.

puzzled :

Erik :

19 Sep 2013 3:34:02pm

Due to obsolete laws, some residual controversy appears to remain regarding free choice of when to step off this mortal coil. When will the god-botherers realise: Anyone who does not own his own life is a slave - owned in body and soul by the dictator who does have control. (Not that all the words amount to anything; a successful exit makes its own rules.)

Scat :

19 Sep 2013 10:06:26pm

My mother died 3 weeks ago. Her death was a good death, one she hoped for. It was the hardest thing I have ever done....to start the process of her death, no intervention, ceasing medication etc. I was her advocate & I suggest that people who read this to ask loved elders how they want to manage their end of life. Be their advocate so they do not have a stressful end & the trauma of their death is dulled ( only slightly ) by the knowledge that their death was " a good one".

finalroadmap.com :

20 Sep 2013 10:57:30pm

Acknowledging that nothing is guaranteed, it is possible to greatly improve your odds on having a “good death”. Be prepared. Consider and document your end of life wishes while healthy, then communicate them with family, loved ones and health care providers. Planning ahead will give you the comfort that others know your wishes and your loved ones the peace of mind of not having to guess ‘what he/she wants’.

Robin :

23 Sep 2013 2:14:36am

What constitutes a "good" death varies from person-to-person. For example, one person might want all their friends and family to be present. Another may want only their life partner or priest present. Others may want no-one present.

I think that, just like we discuss birth and marriage plans, we should discuss (well in advance) with our loved ones, doctors, and carers, what we hope and wish for when our end is approaching. This should include the type and extent of medical care, organ donation, the preferred location, and any last wishes or funeral plans.

Being open and realistic takes away the fear, doubts, and possible regrets many experience before and after a death.

Gary Orton :

18 Jan 2014 12:52:42pm

I am also terminal and as I approach the end trusting those around you have your welfare at heart is also important.

I have had chemotherapy at 3 different day surgeries and would literally trust my death to the nurses in 2 of them, particularly Townsville Medical Oncology. They were the most caring, empathetic people I have ever met anywhere.

Unfortunately there is always the exception; I am currently having therapy in a Newcastle Medical Oncology unit and most of the staff and doctors are lovely. The unit nurse/manager is not, to the extent I have been denied chemo twice in 4 visits. It seems she has a schedule and even with 3 6 weeks notice this cannot be changed by one day.

Would you like your death to be in someone like her hands? Frankly it makes me so frightened I will move hospitals.

So be aware, PLAN also who will be the medical decision-makers around you when the time comes.

witness :

31 Mar 2014 10:36:04am

I wish the emphasis on futile treatment would form part of a 'good death' conversation. Having witnessed two atrocities, the first a dear friend having whole brain radiation when she was dying from metastatic breast cancer (the time gained in days was spent without hair and with dementia and incontinence), and the other, a friend dying who had electric shock treatment when she was dying from cancer and was deemed to be depressed about it. Both horrific and unnecessary and why do we do these things...part of a good death is useless futile treatment being imposed by others being withheld. FUTILE and not pallative. Having witnessed that I have had a very clear conversation with family about staying away from 'treatment'.